摘要：We describe an evidence-based framework to define and assess the impact of quality improvement (QI) in public health. Developed to address programmatic and research-identified needs for articulating the value of public health QI in aggregate, this framework proposes a standardized set of measures to monitor and improve the efficiency and effectiveness of public health programs and operations. We reviewed the scientific literature and analyzed QI initiatives implemented through the Centers for Disease Control and Prevention’s National Public Health Improvement Initiative to inform the selection of 5 efficiency and 8 effectiveness measures. This framework provides a model for identifying the types of improvement outcomes targeted by public health QI efforts and a means to understand QI’s impact on the practice of public health. At a time when taxpayer resources are scarce, government agencies are expected to deliver on broader missions while reducing operating costs. 1–6 As stewards of public funds, agencies must implement programs and deliver services as effectively and efficiently as possible on the basis of the best evidence available. Federal programs are required to engage in rigorous measurement and evaluation and use the findings to facilitate continuous improvement and understand the value of services and programs for improved accountability and decision making. 7 This approach relies on the adoption of valid measures that track progress toward goals, identify areas for improvement, and assess achievement of outcomes. 7,8 In the public health field, quality improvement (QI) is an increasingly recognized approach to maximizing the effectiveness of services while minimizing costs. As defined by Riley et al., public health QI “refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community.” 9 (p6) To date, several initiatives have promoted the use of QI among public health agencies with the goals of reaching these outcomes and building the evidence base. Tools, such as the National Public Health Performance Standards, and initiatives, such as the Turning Point Performance Management Collaborative and the Robert Wood Johnson Foundation–supported Multi-State Learning Collaborative, represent some of the earliest efforts that encouraged health departments to adopt performance management and QI methods as a strategy to strengthen public health systems. 10–12 More recently, new initiatives aimed at integrating QI into the practice of public health have included the Robert Wood Johnson Foundation–funded Communities of Practice for Public Health Improvement, which serves as a forum for public health agencies to exchange best practices related to QI, 13 and the Centers for Disease Control and Prevention’s National Public Health Improvement Initiative (NPHII), through which 73 state, tribal, local, and territorial public health agencies are funded to achieve public health standards and adopt and institutionalize cross-cutting performance management and QI approaches to improve the accountability, efficiency, and effectiveness of their public health programs and services. 14,15 Most recently, the establishment of the Public Health Accreditation Board and its release of version 1.0—and subsequently version 1.5—standards and measures have driven public health agencies to integrate performance management into their daily practice. The Public Health Accreditation Board has further highlighted QI as an important aspect of the performance management system, 16 supporting the Turning Point initiative, which includes QI as a core component of its performance management framework as a demonstrated means to manage change and make improvements based on data. 11 As a result of these efforts, the body of evidence for public health QI is growing, with a focus on the extent to which public health agencies have adopted QI and the kinds of QI processes and tools implemented. 6,12,17–21 However, conceptualizing and assessing outcomes resulting from the implementation of public health QI has proven challenging, in large part because of the diversity of public health contexts 12,20 and the scarcity of evidence-based measurement methods. 5,22,23 Only recently have researchers and practitioners begun to describe or assess outcomes of public health QI in a way that has the potential to demonstrate the impact of this work on public health organizations and the public health system more broadly. 5,22,24,25 Recent studies have described the role of public health QI in addressing service and program processes as well as operational processes. 5,22 Another study highlighted that certain characteristics of QI initiatives correlate with an increased likelihood of attaining stated objectives, including clarity around select measurement parameters such as time frames, baselines, and targets. 24 Although progress has been made, these studies have acknowledged that the evidence base for what works in public health QI is still growing and standardized measures for improvement initiatives targeting operational or programmatic efficiency and effectiveness are lacking. To improve performance, public health practitioners and researchers need to clarify what we hope to achieve and continue to build the evidence base for what works. 5,22,25 In recognition of this need, the Public Health Services and Systems Research national research agenda has focused attention on the following QI research questions: What measures provide the most valid and reliable indicators of the implementation and impact of QI strategies in public health settings? What types of QI strategies have the largest effects on the effectiveness, efficiency, and outcomes of public health strategies delivered at local, state, and national levels? 26 To advance the science and practice of QI outcome measurement, we conceptualized a framework that proposes and defines a standardized way to assess public health QI outcomes related to efficiency and effectiveness. The primary purposes of this QI measurement framework are to (1) support public health agencies’ efforts to achieve demonstrable outcomes, (2) provide a means to aggregate the impact of individual QI initiatives, and (3) advance the science and practice of this emerging field.
